Changing the environment of AIDS risk: findings on syringe exchange and pharmacy sales of syringes in Hartford, CT

Assessing the relationship between syringe exchange, pharmacy, and street sources of accessing syringes and injection drug use behavior in a pooled nationally representative sample of people who inject drugs in the United States from 2002 to 2019

Provision of sterile syringes is an evidence-based strategy of reducing syringe sharing and reusing and yet, access to sterile syringes through pharmacies and syringe exchange programs (SEPs) in the United States remains inadequate. This nationally representative study examined associations between obtaining syringes from pharmacies, SEPs, and sterilizing syringes with bleach and risk of syringe borrowing, lending and reusing syringes in a pooled cross-sectional dataset of 1737 PWID from the 2002-2019 National Survey on Drug Use and Health. Logistic regression was used to produce odds ratios (OR) of the odds of injection drug behaviors after adjusting for obtaining syringes from SEPs, pharmacies, the street, and other sources and potential confounders of race, ethnicity, sex, education, and insurance coverage. Obtaining syringes through SEPs was associated with lower odds of borrowing (OR = .4, CI95% = .2, .9, p = .022) and reusing syringes (OR = .3, CI95% = .2, .6, < .001) compared to obtaining syringes on the street. Obtaining syringes from pharmacies was associated with lower odds of borrowing (OR = .5, CI95% = .3, .9, p = .037) and lending (OR = .5 CI95% = .3, .9, p = .020) syringes. Using bleach to clean syringes was associated with increased odds of borrowing (OR = 2.0, CI95% = 1.3, 3.0, p = .002), lending (OR = 2.0, CI95% = 1.3, 3.0, p = .002) and reusing syringes (OR = 2.4, CI95% = 1.6, 3.6, p < .001). Our findings support provision of syringes through pharmacies and SEPs as a gold-standard strategy of reducing sharing and reuse of syringes in the US.

Redpilling: A professional reflects on white racial privilege and drug policy in American health care

The landscape of American health care is changing under the weight of new knowledge that health care workers-physicians, nurses, and so on-are abusing the drugs that they use within health care. In this article, the author uses ethnographic data (including his own work in American pharmacies over the past two decades) to contextualize how health care's drug abuse epidemic is racially coded to ignore the fact that White Americans are the primary drug abusers-what he calls "redpilling." In pointing out the racial contexts of health care's drug abuse, the author asks whether our national "war on drugs" ought to be recast to see how White racial privilege-the privilege of White Americans to comfortably perform certain actions (and get away with them if they are illegal or morally wrong)-mandates that we move the lens of drug policy from ghettos and ethnic communities to American health care where we have been historically positioned to not identify White American health care workers who work while high.

A preliminary needs assessment of American Indians who inject drugs in northeastern Montana

Background

Injection drug use has not been well documented in American Indians living in the USA. American Indian and Alaskan Natives (AI/ANs) show higher rates of substance use compared to the general population, and have historically been subject to a number of risk factors that are known to increase the likelihood of substance use. AI/ANs also experience increased risk for infectious diseases that are transmitted via injection drug use and/or sexual activity. Harm reduction approaches have been shown to be effective for decreasing risk of disease transmission in at-risk populations, and may be well suited for AI/AN injection drug users residing in rural reservation communities. In this study, we aimed to examine the characteristics of American Indians (AI) who use injection drugs (PWUID) in northeastern Montana to identify needs that could be addressed with harm reduction programming.

Methods

For the present study, we used a respondent-driven sampling approach to generate a sample of 51 self-identified male and female injection drug users ≥18 years of age who were American Indians living on the Fort Peck Indian Reservation. Sampling weights were applied to all analyses using Respondent-Driven Sampling Analysis Tool (RDSAT).

Results

There were no strong recruitment patterns by age, sex, or ethnic identity status of the recruiter or participant, but there were strong within-group recruitment patterns by location within the reservation. The majority of the sample reported initiating substance use before the age of 18. Participants reported significant risk for HIV, hepatitis, and other infectious diseases through their drug use and/or risky sexual behavior. Sixty-five percent reported having reused syringes, and 53% reported drawing from the same filter. Seventy-five percent reported inconsistent condom use during the 3 months preceding the survey, and 53% reported injecting drugs during sex during the 3 months preceding the survey. Only 66% of participants reported having been tested for HIV in the 12 months preceding the survey. The vast majority (98%) of respondents expressed interest in a harm reduction program. Seventy-six percent reported that it was easy or very easy to obtain new syringes.

Conclusions

We documented several risks for blood-borne pathogens, including elevated levels of syringe reuse. Further, we documented significant interest in harm reduction interventions in the present sample of AI/AN injection drug users. Findings suggest a need for increased access to harm reduction programming for AI/AN injection drug users to reduce the transmission of infectious disease and increase access to compassionate care.

Effectiveness of needle and syringe Programmes in people who inject drugs - An overview of systematic reviews

BACKGROUND

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

METHODS

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

RESULTS

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial.

CONCLUSIONS

The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

TRIAL REGISTRATION

The protocol of this systematic review was registered in Prospective Register of Systematic Reviews (PROSPERO 2015: CRD42015026145 ).

Consequences of a restrictive syringe exchange policy on utilisation patterns of a syringe exchange program in Baltimore, Maryland: Implications for HIV risk

INTRODUCTION AND AIMS

Syringe distribution policies continue to be debated in many jurisdictions throughout the USA. The Baltimore Needle and Syringe Exchange Program (NSP) operated under a 1-for-1 syringe exchange policy from its inception in 1994 through 1999, when it implemented a restrictive policy (2000-2004) that dictated less than 1-for-1 exchange for non-program syringes.

DESIGN AND METHODS

Data were derived from the Baltimore NSP, which prospectively collected data on all client visits. We examined the impact of this restrictive policy on program-level output measures (i.e. distributed : returned syringe ratio, client volume) before, during and after the restrictive exchange policy. Through multiple logistic regression, we examined correlates of less than 1-for-1 exchange ratios at the client level before and during the restrictive exchange policy periods.

RESULTS

During the restrictive policy period, the average annual program-level ratio of total syringes distributed : returned dropped from 0.99 to 0.88, with a low point of 0.85 in 2000. There were substantial decreases in the average number of syringes distributed, syringes returned, the total number of clients and new clients enrolling during the restrictive compared to the preceding period. During the restrictive period, 33 508 more syringes were returned to the needle exchange than were distributed. In the presence of other variables, correlates of less than 1-for-1 exchange ratio were being white, female and less than 30 years old.

DISCUSSION AND CONCLUSIONS

With fewer clean syringes in circulation, restrictive policies could increase the risk of exposure to HIV among Injection Drug Users (IDUs) and the broader community. The study provides evidence to the potentially harmful effects of such policies.

Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis

BACKGROUND

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

METHODS

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

RESULTS

There were 12 studies comprising at least 12 000 person-years of follow-up. Exposure to NSP was associated with a reduction in HIV transmission: pooled effect size 0·66 [95% confidence interval (CI) 0·43, 1·01] across all studies, and 0·42 (95% CI 0·22, 0·81) across six higher quality studies (according to the Newcastle-Ottawa tool).

CONCLUSIONS

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Pharmacy nonprescription syringe distribution and HIV/AIDS: a review

OBJECTIVE

To summarize current research findings on pharmacy nonprescription syringe distribution to prevent the spread of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) among injection drug users (IDUs), including research on pharmacist attitudes and behavior, drug user attitudes and behavior, and the health impact on HIV/AIDS risk behavior.

DATA SOURCES

Data were collected using PubMed and PsycINFO through July 2011. Search terms used were pharmacist or pharmacy and syringe or syringe exchange or needle or needle exchange. Two journals (Journal of Urban Health and Journal of the American Pharmacists Association) with a high number of hits were manually inspected. Reference sections for each article also were examined.

STUDY SELECTION

Studies were included if they examined attitudes toward, experiences with, or the impact of pharmacy nonprescription syringe distribution for the purpose of preventing the spread of HIV/AIDS among IDUs in the United States. Studies were excluded that mentioned these topics in passing or did not report empirical results.

DATA SYNTHESIS

47 studies were identified that met the inclusion criteria. Studies included a diverse range of perspectives, including pharmacist viewpoints, IDU attitudes, and evaluations.

CONCLUSION

According to the available literature, many pharmacists express willingness to sell and report selling syringes to customers without a prescription. IDUs show willingness to use pharmacies to obtain syringes. Finally, pharmacy syringe sale and the legalization of this practice appear to have a positive impact on HIV risk behavior. Accordingly, the nonprescription sale of syringe should be promoted. However, the literature remains incomplete and future research is required.

Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness

BACKGROUND

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

METHODS

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

RESULTS

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.

CONCLUSION

Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

The impact of human rights violations and perceptions of discrimination on health service utilization among injection drug users in Delhi, India

The study was conducted from August to December 2007, in two urban, poor neighborhoods in Delhi. A respondent-driven sampling was used to recruit 343 injection drug users who were interviewed with a survey questionnaire that included items of human rights abuses, health service utilization, and sociodemographic characteristics. Multivariate logistic regression with backward selection of variables was conducted with the three outcome variables-service utilization in general care sector, harm reduction, and drug user treatment. Findings suggest advocating for human rights and securing standards of care in improving health care use and future research on documenting human rights abuses occur in health care settings. The study's limitations are noted.

Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews

AIMS

To review the evidence on the effectiveness of harm reduction interventions involving the provision of sterile injecting equipment in the prevention of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission among injecting drug users (IDUs). The interventions assessed were needle and syringe programmes (NSP), alternative modes of needle/syringe provision (pharmacies, vending machines and outreach) and the provision of injecting equipment other than needles/syringes.

METHODS

Systematic searches of the English language literature to March 2007 were undertaken to identify systematic, narrative or meta-analytical reviews (also known as a review of reviews) of the impact of interventions on HCV transmission, HIV transmission or injecting risk behaviour (IRB). Critical appraisal criteria classified the reviews as either high quality ('core') or supplementary: a framework based on the quality of reviews, the reviewers' conclusions and the designs/findings of the primary studies was used to derive evidence statements.

RESULTS

Three core and two supplementary reviews of injecting equipment interventions were identified. According to the proposed framework, this study found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmission; (b) tentative evidence to support the effectiveness of NSP in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NSP (and tentative evidence of an additional impact of pharmacy NSP) in reducing self-reported IRB; and (d) little to no evidence on vending machines, outreach or providing other injecting equipment in relation to any of the outcomes.

CONCLUSIONS

The evidence is weaker than given credit for in the literature. The lack of evidence for effectiveness of NSP vis-à-vis biological outcomes (HCV and HIV incidence/prevalence) reflects the limitations of studies that have been undertaken to investigate these associations. Particularly for HCV, low levels of IRB may be insufficient to reduce high levels of transmission. New studies are required to identify the intervention coverage necessary to achieve sustained changes in blood-borne virus transmission.

Temporal trends in spatial access to pharmacies that sell over-the-counter syringes in New York City health districts: relationship to local racial/ethnic composition and need

Pharmacies that sell over-the-counter (OTC) syringes are a major source of sterile syringes for injection drug users in cities and states where such sales are legal. In these cities and states, however, black injectors are markedly less likely to acquire syringes from pharmacies than white injectors. The present analysis documents spatial and temporal trends in OTC pharmacy access in New York City health districts over time (2001-2006) and investigates whether these trends are related to district racial/ethnic composition and to local need for OTC pharmacies. For each year of the study period, we used kernel density estimation methods to characterize spatial access to OTC pharmacies within each health district. Higher values on this measure indicate better access to these pharmacies. "Need" was operationalized using two different measures: the number of newly diagnosed injection-related AIDS cases per 10,000 residents (averaged across 1999-2001), and the number of drug-related hospital discharges per 10,000 residents (averaged across 1999-2001). District sociodemographic characteristics were assessed using 2000 US decennial census data. We used hierarchical linear models (HLM) for descriptive and inferential analyses and investigated whether the relationship between need and temporal trajectories in the Expanded Syringe Access Demonstration Program access varied by district racial/ethnic composition, controlling for district poverty rates. HLM analyses indicate that the mean spatial access to OTC pharmacies across New York City health districts was 12.71 in 2001 and increased linearly by 1.32 units annually thereafter. Temporal trajectories in spatial access to OTC pharmacies depended on both need and racial/ethnic composition. Within high-need districts, OTC pharmacy access was twice as high in 2001 and increased three times faster annually, in districts with higher proportions of non-Hispanic white residents than in districts with low proportions of these residents. In low-need districts, "whiter" districts had substantially greater baseline access to OTC pharmacies than districts with low proportions of non-Hispanic white residents. Access remained stable thereafter in low-need districts, regardless of racial/ethnic composition. Conclusions were consistent across both measures of "need" and persisted after controlling for local poverty rates. In both high- and low-need districts, spatial access to OTC pharmacies was greater in "Whiter" districts in 2001; in high-need districts, access also increased more rapidly over time in "whiter" districts. Ensuring equitable spatial access to OTC pharmacies may reduce injection-related HIV transmission overall and reduce racial/ethnic disparities in HIV incidence among injectors.

Hepatitis B Virus Prevalence and Vaccination Rates among Hispanic Injection Drug Users Participating in a Vaccination Campaign

Injection drug users are at high risk for hepatitis B virus infections. Nevertheless, few concerted efforts have been made to provide injectors with access to an available, safe, and effective vaccine. A campaign to screen and vaccinate injectors was conducted at syringe exchange programs in Chicago, Illinois, and Hartford and Bridgeport, Connecticut. Injectors with no evidence of past hepatitis B infection were eligible for vaccination. Eligible injectors were offered the three doses of vaccine and questioned about their past and current drug use, their sociodemographics, their understanding of hepatitis infections, and their motivation for participating in the study. Disease prevalence, vaccination rates, and the answers to study questions were analyzed comparing the sample of Hispanic to non-Hispanic injectors. We screened 1970 injectors, 860 of whom were eligible for vaccination. Of those, 591 received at least one dose of the vaccine. Hispanics comprised 30.9% of those screened, 24.9% of those eligible, and 25.2% of those receiving at least one dose. Hispanics were more likely than non-Hispanic Whites or non-Hispanic Blacks to have already been infected with hepatitis B—55.6% for Hispanics versus 46.5% for non-Hispanics. Although it is impossible to generalize from our study population to Hispanic injectors as a whole, it seems apparent that if greater efforts are made to promote hepatitis B vaccination among Hispanics, high rates of vaccination can be achieved.

Increasing syringe access and HIV prevention in California: findings from a survey of local health jurisdiction key personnel

This article presents results from the first survey of California local health jurisdictions (LHJs) subsequent to passage of legislation that allows for over-the-counter pharmacy sales of syringes. In 2004 Governor Arnold Schwarzenegger signed Senate Bill 1159 (SB1159) into law to "prevent the spread of HIV, hepatitis and other blood-borne disease among drug users, their sexual partners and their children." This legislation permits counties and cities to authorize a local disease prevention demonstration project (DPDP). Once authorized, a DPDP permits individuals to legally purchase and possess up to ten syringes from registered pharmacies without a doctor's prescription. From June to August 2005, we surveyed health departments in all 61 LHJs to assess implementation status of SB1159. Fifty-seven (93%) LHJs responded. Nine (16%) had approved a DPDP by August 2005, 17 (30%) were in the process of obtaining authorization, and 18 (32%) anticipated that SB1159 would never be authorized in their LHJ. Among LHJs that do not plan to approve a DPDP (n = 18), the reasons included: strong community opposition (41%), competing priorities (35%), law enforcement opposition (29%), and little or no interest among pharmacies (29%). In LHJs that have authorized a DPDP, 31.4% of pharmacies registered to legally sell nonprescription syringes. Preliminary results indicate that local coalitions, comprised of public health, waste management and pharmacy officials, have been instrumental in facilitating DPDP authorization. Further research is needed to identify facilitators and barriers to adopting SB1159, to identify areas for improving technical assistance to implementers, and to assess the public health impact of the legislation.

Prevalence of psychiatric disorders across Latino subgroups in the United States

OBJECTIVES

We examined the prevalence of depressive, anxiety, and substance use disorders among Latinos residing in the United States.

METHODS

We used data from the National Latino and Asian American Study, which included a nationally representative sample of Latinos. We calculated weighted prevalence rates of lifetime and past-year psychiatric disorders across different sociodemographic, ethnic, and immigration groups.

RESULTS

Lifetime psychiatric disorder prevalence estimates were 28.1% for men and 30.2% for women. Puerto Ricans had the highest overall prevalence rate among the Latino ethnic groups assessed. Increased rates of psychiatric disorders were observed among US-born, English-language-proficient, and third-generation Latinos.

CONCLUSIONS

Our results provide important information about potential correlates of psychiatric problems among Latinos that can inform clinical practice and guide program development. Stressors associated with cultural transmutation may exert particular pressure on Latino men. Continued attention to environmental influences, especially among third-generation Latinos, is an important area for substance abuse program development.

Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence

This first international review of the evidence that needle syringe programs reduce HIV infection among injecting drug users found that conservative interpretation of the published data fulfills six of the nine Bradford Hill criteria (strength of association, replication of findings, temporal sequence, biological plausibility, coherence of evidence, and reasoning by analogy) and all six additional criteria (cost-effectiveness, absence of negative consequences, feasibility of implementation, expansion and coverage, unanticipated benefits, and application to special populations). The Bradford Hill criteria are often used to evaluate public health interventions. The principal finding of this review was that there is compelling evidence of effectiveness, safety, and cost-effectiveness, consistent with seven previous reviews conducted by or on behalf of U.S. government agencies. Authorities in countries affected or threatened by HIV infection among injecting drug users should carefully consider this convincing evidence now available for needle syringe programs with a view to establishing or expanding needle syringe programs to scale.

Values and identity: the meaning of work for injection drug users involved in volunteer HIV prevention outreach

Most HIV behavioral interventions provide participants with preventive information emphasizing how not to behave, and have neglected to provide attractive and feasible alternatives to risky behavior. Interventions that emphasize cultural strengths may have more powerful effects and may help remove the stigma of HIV, which has hampered prevention efforts among African American communities. Starting in 1997, the SHIELD (Self-Help in Eliminating Life-Threatening Diseases) intervention trained injection drug users (N=250) to conduct risk reduction outreach education among their peers. Many participants saw their outreach as "work," which gave them a sense of meaning and purpose and motivated them to make other positive changes in their lives.

Neighborhood differences in patterns of syringe access, use, and discard among injection drug users: implications for HIV outreach and prevention education

The article presents results from the Syringe Access, Use, and Discard: Context in AIDS Risk research project comparing two neighborhoods by (1) socioeconomic and demographic characteristics; (2) patterns of syringe access, use, and discard; and (3) encounters with a local human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) outreach project targeted to injection drug users (IDUs). The results show that IDUs in more economically advantaged neighborhoods were more likely to acquire syringes from a single source (rather than multiple sources), more likely to inject alone in their own residence (rather than public injection locales), and more likely to dispose of syringes in private garbage cans rather alleys or dumpsters. These results are further associated with the likelihood of encountering street outreach workers, with IDUs in more affluent neighborhoods much less likely to have any such contacts. Based on the different patterns of access, use, and discard evident in each neighborhood, the results indicate that different and more carefully tailored local outreach and prevention strategies are urgently needed.

Effects of increasing syringe availability on syringe-exchange use and HIV risk: Connecticut, 1990-2001

Syringe-exchange programs (SEPs) in Connecticut operate with caps on the number of syringes exchanged per visit. We investigated the effects of legislation increasing the cap on drug injectors' access to clean syringes through the SEPs in New Haven and Hartford. The mixed design of this study included longitudinal and cross-sectional data from individuals and ecological data from program operations. Five parameters-syringe return rate, syringes per visit to the SEP, syringe reuse rate, syringe human immunodeficiency virus (HIV) prevalence, and syringe sharing-were monitored through syringe tracking and testing of SEP syringes and by interviewing injectors. Two increases in the cap-from 5 to 10 and then from 10 to 30-had little effect on the five parameters that measured injectors' access to clean syringes. In contrast, access to clean syringes increased when the New Haven SEP first began operations, when syringes first became available at pharmacies in Hartford, and when the agency running the Hartford SEP changed. Legislation providing piecemeal increases in the cap may not, by themselves, be sufficient to increase injectors' access to clean syringes and decrease the risk of human immunodeficiency virus transmission in this population.

Report of the Council on Scientific Affairs: methadone maintenance and needle-exchange programs to reduce the medical and public health consequences of drug abuse

Extensive evaluation studies show that methadone maintenance therapy (MMT) reduces heroin use and associated problems in a cost-effective manner, without negative public health impact. MMT is limited by inadequate funding and understanding of relevant research, extensive regulation, and limits on the freedom of physicians to provide methadone in a variety of medical settings. Broad-based medical, public health, and scientific support exists for expansion of MMT with greater emphasis on consistency and quality, and provision of ancillary services. Programs for the exchange, free distribution, and legal pharmacy sale of needles and syringes reduce injection drug use and prevent the spread of bloodborne pathogens; drug abuse treatment and other services are important components. Neither strategy increases existing drug use nor leads to drug use initiation. The scientific literature supports assertions that drug abuse issues should be treated primarily as medical and public health rather than criminal justice issues. The effectiveness of both strategies warrants increased support for services, easing of federal and state restrictions governing their availability, and advocacy in their support.

Patterns of needle acquisition and sociobehavioral correlates of needle exchange program attendance in Baltimore, Maryland, U.S.A

OBJECTIVES

This study examined factors associated with obtaining syringes from a needle exchange program (NEP) and other safer sources in Baltimore, Maryland, U.S.A.

DESIGN AND METHODS

A cross-sectional face-to-face survey was administered to 741 current drug injectors recruited by snowball sampling techniques. A brief open-ended interview was conducted on a subsample.

RESULTS

Most (85%) participants obtained needles from street needle sellers. Only 8% obtained their needles exclusively from safer sources (NEPs, pharmacies, hospitals, or patients with diabetes). Cocaine use was associated with obtaining needles from the NEP but not from exclusively safer sources. Obtaining needles from only safer sources was associated with being female and less frequent needle sharing and shooting gallery attendance. Among HIV-seropositive participants, those who were diagnosed before the year that the NEP began were more likely to obtain needles from safer sources. Participants who sold needles reported that it was easy to make used needles appear to be unused, and some admitted to selling used syringes as new.

CONCLUSIONS

Street needle sellers are an important source of needles for drug injectors, and few injectors appear able to determine whether these needles are clean. Individual sealing of diabetic syringes may reduce the risk of blood-borne infections by enabling both drug injectors and patients with diabetes to better judge the sterility of the needles they purchase.

High Risk Drug Use Sites, Meaning and Practice: Implications for AidS Prevention

A study of drug use locations in Hartford, CT, Is designed to understand the environmental and social conditions within “high risk sites” where drug users inject drugs or smoke crack, In order to develop AIDS prevention models that build upon the physical and social organization of these locations. The study assesses high-risk sites characterized on the basis of type of location or structure, presence and strength of gatekeepers, and presence and strength of HIV prevention opportunities and pressures. A combination of ethnographic, epidemiological, and social network methods are used to document the characteristics, social organization, natural history, and dynamics of these sites, the network relations of site users, and the various opportunities for, or barriers to, on-site social-level HIV prevention intervention. This paper provides an overview of the study and presents preliminary findings, Including the degree to which drug injectors and crack smokers use specific types of sites in Hartford. The paper also discusses the ways these findings Inform development of on-site, type-specific and peer-led or structural HIV-prevention Interventions.

Harm reduction theories and strategies for control of human immunodeficiency virus: a review of the literature

AIM

To provide a comprehensive review of the literature on harm reduction theories and strategies related primarily to licit and illicit drug use.

BACKGROUND

Although human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) disease transmission is well understood, it continues to spread, particularly among injection drug users (IDUs). Despite early indications that HIV would be contained within the IDU community, it is spreading to non-IDU sexual partners and to children of IDUs, threatening a more widespread epidemic.

METHODS

An examination of research studies and theoretical writings including reviews and policy papers published in English between 1990 and 2000.

RESULTS

Harm reduction does not seek to eliminate drug use; it focuses on minimizing the personal and social harms and costs associated with drug use and spread of HIV. It seeks to ameliorate conditions surrounding drug use responsible for the spread of HIV in the IDU community: unequal access to health services; sharing of infected needles; racial and social discrimination; poverty; exposure to street violence; inadequate housing; lack of employment; poor general or mental health and other demographic and social determinants. Some controversial harm reduction strategies are described: methadone maintenance programmes, illegal drugs dispensing under controlled conditions, needle exchanges, HIV testing, vein maintenance, safe-sex and would-care programmes.

CONCLUSION

The main challenge is to get IDUs to protect themselves against HIV when suffering physical and social privations and addiction needs. Diverse perspectives on harm reduction are problematic with consequences for success of drug use initiatives. Practical, ethical and theoretical complexities exist but further research is needed to build support for a harm-reduction orientation in practice and policy formulation.

Pharmacy access to sterile syringes for injection drug users: attitudes of participants in a syringe exchange program

OBJECTIVE

To examine attitudes of participants of a van-based syringe exchange program (SEP) toward the hypothetical prospect of pharmacy-based syringe access.

DESIGN

One-time, cross-sectional survey.

SETTING

Baltimore, Maryland.

PARTICIPANTS

206 injection drug users who participate in the Baltimore SEP.

INTERVENTIONS

Face-to-face interviews.

MAIN OUTCOME MEASURES

Location preferred for obtaining syringes, drug and syringe use, past experience with pharmacies, and willingness to pay.

RESULTS

The sample was 67% men, 95% African American, and 95% unemployed; mean age was 39.8 years. A total of 19% of respondents had bought syringes at a pharmacy during the prior six months. Some 37% reported having been turned down when asking for syringes at a pharmacy, most commonly due to lack of identification to prove diabetic status (50%). If legal restrictions were lifted, 92% of respondents would obtain syringes from pharmacies, and would be willing to pay a mean price of $0.80 (median = $1.00) per syringe. Women were more likely than men to report the intention to switch from van-based SEP to pharmacy (57% versus 38%, p = .045).

CONCLUSION

If current legal restrictions were lifted, pharmacies would be a viable syringe source appealing particularly to women, suggesting gender-specific access issues that should be addressed. The per-syringe price that study participants would be willing to pay exceeds typical retail prices, suggesting that pharmacists could charge enough per syringe to recoup operational costs.